Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition
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Dr Ramona Coelho
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An excellent interview of Dr Ramona Coelho by Jonathon Van Maren was published in the European Conservative on April 24, 2024.
As stated by Van Maren, Dr Coelho is a family physician in London, Ontario, with a practice largely serving marginalized patients, she has testified before Parliament, laid out the dangers of legal euthanasia on TV and in print, and presciently warned policymakers of many of the scenarios we now see unfolding. Dr Coelho is a leading voice opposing Canada's euthanasia regime.
Van Maren begins the article by bringing up two of the most recent Canadian euthanasia stories and commenting on the issue of euthanasia for mental illness alone:
For the past several years, the euthanasia horror
stories unfolding in Canada have captured the attention of the press on
both sides of the Atlantic. I have detailed many of them in my reporting; as I write this, a desperate father is battling in court to prevent his healthy 27-year-old autistic daughter from dying by doctor-administered lethal injection; another Canadian has been approved for euthanasia after developing bedsores while waiting for necessary healthcare that is increasingly difficult to obtain.
At the end of January, the Trudeau government delayed, for the second time,
their plan to expand euthanasia eligibility to Canadians struggling
solely with mental illness. Initially, a strong majority of Canadians
supported legal euthanasia in limited circumstances. The events of the
past several years have begun to erode that support, and the
Conservative Party is campaigning on a promise to pass legislation
banning euthanasia for mental illness. It is an incredibly pressing
issue: if suicide-by-doctor were to be made available to the mentally
ill, Canada’s ever-rising euthanasia death rate would spike overnight.
Dr Coelho defines what the term MAiD means:
Medical Assistance in Dying (MAiD) is the Canadian term that refers
to both euthanasia and assisted suicide, although up to this point 99.9%
of cases have been euthanasia (physician administered lethal cocktail
to induce death, usually by IV) so I think it’s accurate and clearer to
refer to this as euthanasia. However, it is possible that there might be
more cases of assisted suicide (patient self-administers the lethal
cocktail of drugs) in coming years as both are permitted. I will refer
to it as MAiD just for ease and as some very few cases do involve
assisted suicide.
Van Maren then asks Dr Coelho to comment on euthanasia for mental illness:
MAiD really never should have been an option for those with mental illness. Canadians face major barriers to access mental health care and numerous Canadian psychiatrists
have voiced serious reservations about this expansion. We do not even
understand how clinically to distinguish between the overwhelming
majority of those with mental illness, who recover with suicide
prevention and services, and those very few who might not. Such an
expansion would allow healthcare practitioners arbitrarily to decide who
deserves suicide prevention and who is deemed eligible for MAiD,
potentially placing many Canadians’ lives at risk.
The legislation permitting MAiD for mental illness should have been
permanently abandoned. But despite recommendations from its most recent
parliamentary committee and most Canadian provinces asking that the
legislation be indefinitely paused, the government has chosen simply to
delay its implementation once again, this time until 2027. Politically,
the delay in implementation of this legislation, rather than stopping it
altogether, seems imprudent for the current government, as it may
become a significant election issue. I would say Canadians are
increasingly recognizing the risks of expanding MAiD to include
individuals whose sole medical condition is mental illness.
Dr Coelho then comments on possible further expansions of MAiD in Canada:
And besides this, we still have the 2023 parliamentary recommendations to include MAiD for “mature” children
and advance directives for euthanasia next. MAiD was initially
introduced as an exceptional procedure to be used only for those near
death with intolerable suffering, but once society embraces the
intentional ending of one’s life as a treatment for suffering, it becomes practically impossible to contain, with Canada being a case in point.
Dr Coelho then comments on the concerns with medical safety:
In February 2024, the Canadian Human Rights Commission
expressed ongoing concern over reports indicating that individuals with
disabilities opt for MAiD due to a lack of essential support services.
The CHRC is joined
by UN human rights experts, Canadian disability groups, Indigenous
advocates, social justice groups, and numerous medical and legal
professionals in these concerns.
I was interviewed for a documentary
featuring the tragic MAiD death of Rosina Kamis, who, citing poverty
and loneliness, chose MAiD due to insufficient support. Some Canadian
bioethicists argue
that MAiD under “unjust social circumstances” is a form of “harm
reduction.” However, this is not a free autonomous choice, but death
driven by desperation and structural inequalities.
Messages
promoting suicide and easier access to lethal means heighten suicide
risks. MAiD exacerbates these dangers, endangering vulnerable
individuals by increasing the likelihood of being induced into a
premature death. Additionally, healthcare providers’ often inaccurately
rate the quality of life of individuals with disabilities as poor,
which may lead to their biases leading to suggesting or approvals of
MAiD, particularly when patients are experiencing transient low points
in their lives.
Dr Coelho then comments on the model practise standard:
Health Canada’s “Model Practice Standard for Medical Assistance in Dying”
suggests informing patients about MAiD if the practitioner suspects it
aligns with patient values and preferences. In contrast, other
jurisdictions discourage or prohibit raising
death as a treatment option due to concerns about undue patient
pressure. The model practice standard’s stance on “conscientious
objection” supports “effective referral” of patients. This means that,
if a physician is concerned that MAiD is not a patient’s best option,
they must still refer the patient to ensure access to MAiD, instead of
pausing or stopping the process.
Examples of these unsafe policies are evident in MAiD training videos.
In one, an instructor recognizes that patients may choose MAiD for
unmet psycho-social needs, suggesting referral for MAiD completion if
discomfort arises. Another instructor in a separate video advises
continuing the MAiD process even if a practitioner believes a patient
doesn’t qualify for MAiD, suggesting doctor shopping is acceptable.
Certain regions in Canada have the highest MAiD death rates globally. By 2022, nearly 45,000 MAiD deaths occurred across Canada since its legalization—almost 13,000 in 2022 alone, with estimates for 2023 approaching 16,000. Canada’s MAiD regime has chosen to prioritize accessibility over patient safety.
Dr Coelho then comments on her experience with the disability community:
Realizing my political naivety while advocating for legislative
change has been a profoundly sad and eye-opening experience. Despite the
government’s repeated assurances of listening to the concerns of
persons with disabilities and their advocates, the reality witnessed during parliamentary hearings has been disheartening, as their voices are frequently disregarded or dismissed.
Throughout these hearings, committee members have consistently
challenged the credibility of accounts detailing abuses within the
Medical Assistance in Dying (MAiD) system. They assert an unwavering
trust in MAiD assessors, portraying them as professionals deserving of
complete faith and trust to get it right every time. However, this
confidence is inconsistently applied, as committee members often
interrupt and question the integrity of medical and legal experts
expressing caution or offering alternative perspectives.
Furthermore, the presence of physicians who are now part of the
government on MAiD parliamentary committees has not resulted in the
expected depth of medical expertise or unbiased guidance. Instead, their
contributions have often been marked by bias,
with loaded questions designed to limit responses and paint concerned
witnesses as advocating for prolonged suffering. This portrayal is
starkly at odds with the reality faced by patients who endure lengthy
waits for treatment. This waiting for care and being neglected by our
society and health care system wears people down and can lead to
choosing MAiD as the only accessible option.
Dr Coelho then comments on the euthanasia lobby:
Behind the scenes, powerful lobby groups
in Canada wield significant influence in shaping the debate surrounding
the expansion of MAiD. These groups, backed by substantial funding for
government relations, dictate the trajectory of discussions, often
overshadowing the voices of the underfunded and marginalized disability
community. Despite the government’s claims of inclusivity, the reality
is that this debate has been primarily driven by powerful interests,
rather than the voices of those directly affected.
In essence, the legislative process surrounding MAiD in Canada has
exposed systemic flaws and power imbalances, highlighting the urgent
need for genuine inclusivity and meaningful dialogue that centers on the
experiences and concerns of the real stakeholders, the disability
community, which is most directly impacted by these policies.
Coelho is then asked about what must be done to reduce MAiD:
Thomas Insel’s book Healing
drives home the critical role community life, support networks, and
purpose have in dictating mental health outcomes, thereby highlighting
the need for proactive measures. Firstly, the government must fulfill
its duty to ensure everyone gets timely care, counseling, and the
community resources they need. It’s unfortunate that we’re offering
death as an option without properly supporting people who are
struggling. At the same time, establishing a national suicide prevention framework is imperative to mitigate the risk factors that could contribute to MAiD decisions.
Palliative care centers have to be prioritized, offering a range of
services including pain management, emotional support, end-of-life
planning, and counseling individuals facing terminal illness, alongside
robust access to disability and mental health services. This entails a
concerted effort to build expertise, expand medical care systems, and
ensure widespread accessibility.
Investment in community systems is essential too, fostering
relationships and a sense of purpose and belonging. By organizing
regular community gatherings, support groups, and educational workshops,
communities can forge stronger bonds, mitigating feelings of isolation
and despair. On the ground level, everyone can be involved in making
sure neighbours and family members feel they are needed and cared for.
Furthermore, Canada’s commitment to the UN Convention on the Rights of Persons with Disabilities
must be upheld, ensuring the provision of essential services and
support for those with disabilities and chronic illnesses. The
government has to address the systemic lack of social, economic, and
health supports in order to alleviate the suffering that may otherwise
drive individuals towards MAiD. We know that suffering from social and
economic deprivation actually increases overall suffering from disability as it becomes conflated.
In essence, reducing the number of victims under Canada’s MAiD regime
requires a comprehensive approach. Only through concerted efforts
across these fronts can Canada ensure the dignity and well-being of its
citizens, particularly those facing vulnerability and suffering. We need
to make people feel they can live with dignity.
Dr Coelho is then asked what a future government must do:
Sadly, many Canadians remain unaware of the risks of our MAiD regime.
As I mentioned, once a society embraces ending life as a solution to
suffering, containing this procedure becomes nearly impossible.
Tragically, the victims of this system are dead and can be forgotten,
silenced, unable to recount the injustices that may have influenced
their “choosing” death.
Therefore, to start, completely repealing Bill C-7 is imperative.
Anything less is unacceptable to the disability community and greatly
perpetuates the risks that death is driven by unjust circumstances.
There is also an urgent need to redefine the terms used in legislation,
particularly ambiguous terms like reasonably foreseeable natural death
(RFND). Through broad interpretations, individuals with potentially
years of life ahead of them are prematurely ending their lives through
the RFND track—a practice that was intended only for those in the final
stages of life. Moreover, we have people who are simply stating they
will refuse care to make themselves sick enough to qualify for RFND;
MAiD should only be available to those with a disease prognosis of six months or less, not to individuals deliberately inducing sickness to qualify.
It is necessary to stem the influence of powerful lobby groups and
expansionist medical advocacy organizations like the Canadian
Association of MAiD Assessors and Providers (CAMAP). CAMAP received 3.3 million
Canadian dollars in funding from Health Canada to educate MAiD
assessors and providers and has many problematic guidance policies. A
balanced independent panel of experts, as urged by the Canadian Human
Rights Commissioner, should be convened to review the MAiD regime. This
panel should guide legislative amendments, Health Canada policies, and
provincial regulatory bodies to increase patient safety.
Many existing policies clearly require revision, including raising
MAiD unsolicited, enforced mandatory referrals, and the worrisome trend
of integrating MAiD into all care facilities. Ideally, a civil board
comprising a multidisciplinary team should evaluate each case before
approval to mitigate choices to die that are driven by structural
inequalities. We also need better, publicly available, data collection
all around.
This is not merely a matter of individual autonomy; it is a public
safety concern that is affecting marginalized and disabled individuals.
When discussing autonomy, we must consider relational autonomy—what we
owe to each other and society as a whole. MAiD is a public policy, so we
must consider the well-being of all—not just those seeking to end their
lives on their own terms.
Previous articles by or articles concerning Dr Ramona Coelho (Article links).